Transcript Faculty Template 54 x 36

NECROTIZING ENTEROCOLITIS (NEC)
Rhonda J. Petty, BSN, RN
East Carolina University
College of Nursing, Greenville, North Carolina
Pathophysiology/Risk Factors
Clinical Signs/Bell’s Staging
•*Prematurity: the most consistently identified risk factor!
•Intestinal Ischemia & Inflammation: hypoxia,
hypoperfusion, enteral feedings and abnormal colonization of
the gut lead to epithelial cell injury and inflammation. Premature
infants have an increased inflammatory response which further
injures the compromised gut. Secretory IgA, a protective agent
against bacteria, is deficient in the premature gut.
•Enteral Feedings: Gastrointestinal immaturity causes
decreased motility leading to stasis of enteral feedings and
fermentation, overgrowth of bacteria, and gaseous distension
which causes pneumatosis, increased intraluminal pressure
and decreased blood flow.
•Other Risk Factors associated with NEC: Birth
weight <1,500 gm, intrauterine growth restriction, pregnancyinduced hypertension, feedings of infant formula, maternal
chorioamnionitis, maternal smoking, systemic antibiotic therapy,
hemodynamically significant patent ductus arteriosis, umbilical
catheters and- although a causal relationship is not yet knownblood transfusions.
Nursing Implications
• Promote the use of mother’s breast
milk! Nurses play a pivotal role in encouraging
mothers to provide breast milk for their infants and
providing teaching on bringing in and maintaining their
milk supply.
• Implement standardized feeding guidelines
and a well-defined approach to feeding
intolerance : standardized guidelines promote
awareness of the risk factors and early signs of NEC.
• Notify physician or NNP of any
systemic or GI signs of NEC such as:
apnea, bradycardia, hypothermia, lethargy, poor feeding,
vomiting, increasing gastric residuals, bloody or bilious
residuals, mild abdominal distension, bloody stools.
• Know the risk factors and always maintain a
high index of suspicion for NEC!
Review
of Bell's
stages
Clinical findings
Apnea and
bradycardia,
Stage I
temperature
instability
Apnea and
bradycardia,
Stage II A
temperature
instability
Radiographic findings
Gastrointestinal
findings
Normal gas pattern or
mild ileus
Gastric residuals, occult
blood in stool, mild
abdominal distention
Ileus gas pattern with
one or more dilated
loops and focal
pneumatosis
Grossly bloody stools,
prominent abdominal
distention, absent bowel
sounds
Thrombocytopenia Widespread
Stage II B and mild metabolic pneumatosis, ascites,
acidosis
portal-venous gas
Abdominal wall edema
with palpable loops and
tenderness
Mixed acidosis,
oliguria,
Stage III A
hypotension,
coagulopathy
Shock,
Stage III deterioration in
B
laboratory values
and vital signs
Prominent bowel loops,
Worsening wall edema,
worsening ascites, no
erythema and induration
free air
Perforated bowel
Pneumoperitoneum
(Gordon, et al,
2007).Clark, 2007)
Preventive Strategies
•Early/Preferred feedings of breast milk:
Breast fed infants are 6-10 times less likely to develop NEC
than formula fed infants. Epidermal growth factor, which
limits ileal damage from bile acids is found in breast milk
and is not present in infant formula.
•Standardized feeding guidelines: written
guidelines replace daily feeding orders and contain
standard thresholds on how to manage signs of feeding
intolerance and criteria for discontinuing feedings.
Implementing such guidelines reduces the risk for NEC by
up to 87% for infants <2500gms.
•Probiotics: increase gut motility, control inflammatory
cytokines and limit the growth of bacteria. Probiotics
effectively reduce the incidence and mortality of NEC,
however, more studies are necessary to determine a safe
and effective approach.
•Ibuprofen vs Indomethacin to treat PDA: a
meta-analysis of 15 studies showed the risk of NEC
decreases with the use of ibuprofen over indomethacin.
•Maintain awareness of potential risk factors!
References
Chu, A., Hageman, J. & Caplan, M. (2013). Necrotizing enterocolitis: Predictive
Markers and preventive strategies. Neoreviews 14(3), 113-119.
doi: 10.1542/neo.14-3-e113
Gephart, S., McGrath, J., Effken, J. & Halpern, M. (2012). Necrotizing enterocolitis
risk. Advances in Neonatal Care 12(2), 77-87.
doi: 10.1097/ANC.0b013e31824cee94
Gordon, P., Swanson, J., Attridge, J. & Clark, R. (2007). Emerging trends in acquired
neonatal intestinal disease: is it time to abandon Bell’s criteria? Journal of
Perinatology 27, 661-671. Retrieved from
http://www.nature.com/jp/journal/v27/n11/pdf/7211782a.pdf
Gregory, K., DeForge, C., Natale, K., Phillips, M. & VanMarter, L. (2011).
Necrotizing Enterocolitis in the premature infant: Neonatal nursing
assessment, disease pathogenesis, and clinical presentation. Advances in
Neonatal Care 11(3), 155-164. doi: 10.1097/ANC.0b13e31821baaf4
Horton, K, & Trotter, C. (2005). Pathophysiology and current management of
necrotizing enterocolitis. Neonatal Network 24(1), 37-46.
Parker, L. (2013). Necrotizing enterocolitis: Have we made any progress in reducing
the risk? Advances in Neonatal Care 13(5), 317-324.
doi: 10.1097/ANC..0b013e31829a872c
Schurr, P. & Perkins, E. (2008). The relationship between feeding and necrotizing
enterocolitis in very low birth weight infants. Neonatal Network 27(6),
397-407.